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Reimbusement Effects on Quality
Pages 212-235

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From page 212...
... This chapter reviews the available information on the effects of reimbursement on dialysis patient mortality, hospitalization, dialysis unit staffing, and innovation. The focus is entirely on dialysis; there are no studies of the effect of reimbursement on quality in transplantation.
From page 213...
... Specifically, with respect to the effect of the composite rate on mortality, the study reported that "evidence of a correlation between changes in mortality and the extent of composite rate changes was not found, i.e., mortality did not rise more where the composite rate changes were larger" (Held et al., 1987) The authors noted, however, that further analysis was needed to draw firm conclusions.
From page 214...
... examined the effect of the 1983 composite rate price change on treatment time and of treatment time on the mortality during a 2-year followup period of the 1982 and the 1984 incident patient cohorts. They found that average treatment time decreased by 6 percent (from 5.0 to 4.7 hours)
From page 215...
... Finally, there are reasons to think that providers have adapted to reimbursement reductions in ways that dampened the effects on patient mortality. Dialysis units can respond to economic constraints in many ways that protect their core activity of providing dialysis treatment to ESRD patients.
From page 216...
... Held (Urban Institute, personal communication, 1990) analyzed data for ESRD admissions and length of stay for incident dialysis patient cohorts from 1979 through 1985.
From page 217...
... suggests that average dialysis treatment time affects hospitalization rates and days. They estimate that an increase of treatment time by one hour is associated with a decrease of 4 to 11 percent in hospital days, with diabetic patients experiencing the largest effect.
From page 218...
... Using these data, they calculated medical staff hours per patient per week for independent as well as hospitalbased outpatient dialysis units, including total, registered nurse (RN) , licensed practical nurse (LPN)
From page 219...
... Our social workers now spend much of their time in crisis management and in routine activities such as those involved in providing patient transportation. They are increasingly responsible for obtaining and maintaining insurance information.
From page 220...
... They found that independent units with higher standardized reimbursement rates in 1982 had higher levels of RNs and other medical staff (LPNs, nursing assistants, and technicians) ; social worker and dietitian hours per patient per week showed no clear pattern as a function of price differences.
From page 221...
... In 1987, hospital units with the highest standardized price did show the highest number of RN hours per patient-week. However, this relationship did not hold for other nursing personnel, social workers, or dietitians; their hours were stable regardless of standardized price.
From page 222...
... Technicians, by contrast, are trained only to deliver dialysis treatments. Specific effects of the staffing changes, then, include the following: direct clinical supervision of patients is reduced; clinical information on specific patients is less readily available to physicians as they make rounds; crisis management capability is reduced; and the probability of errors in comprehensive patient management is increased.
From page 223...
... Finally, state laws and regulations vary widely in the extent to which they limit or allow direct patient care by technicians and to which they specify the relationship between nurses and technicians.8 Social Workers Social worker time has declined and ratios of social workers to patients have increased in the past decade. Held and colleagues (199Oa)
From page 224...
... from an accredited graduate school.l° In recent years, some dialysis facilities have hired social workers without a master's degree, although there are no data on the extent of this practice. Facility managers, responding to continued economic pressures, have argued that such highly trained individuals are not needed for the routine functions now performed by many social workers.
From page 225...
... Datient management and patient outcomes. r D Implications of Changing Staff Patterns for Quality The combined effect of declining real reimbursement rates and increasing salaries and wages provides strong incentives to dialysis units to alter staffing patterns.
From page 226...
... Major clinical innovations, such as cyclosporine for preventing rejection of the transplanted kidney and erythropoietin for treating anemia in dialysis patients, have resulted from progress in basic scientific research. Such developments are not likely to be influenced by ESRD reimbursement policy.
From page 227...
... First, they imposed economic limits on all dialysis units and gave providers strong incentives to search for operational efficiencies. Provider incentives, in turn, encouraged manufacturers and suppliers to engage in substantial price competition in the competitive product market.
From page 228...
... It also reduced the differential between hospital-based and independent dialysis units substantially, thus eliminating any research support from this source. Peritoneal Dialysis The composite rate affected peritoneal dialysis differently than it did hemodialysis.
From page 229...
... The composite rate, however, paid providers the same for an in-center and a home treatment, for both hemodialysis and peritoneal dialysis. The margins on CAPD fluids thus provided an economic incentive for its use, and as its clinical effectiveness improved, peritoneal dialysis became the treatment modality for more than 15 percent of patients.
From page 230...
... 3. Data strongly suggest that decreased reimbursement has led to decreased staffing in dialysis units, to shifts from nurses to technicians, and to important reductions in social worker and dietitian staffing.
From page 231...
... Although none of these studies constitute conclusive proof of the adverse effects of prior reductions in reimbursement on patient outcomes, none rule out such an effect and none suggest that reimbursement reductions are contributing to improved quality of care. These data have important implications for reimbursement policy.
From page 232...
... Actual and proposed reimbursement policy encouraged the search for treatment efficiency and also intersected with the development of clinical opinion that, in effect, sanctioned shorter treatment time. Moreover, patient preferences, once shorter treatment became a clinical option, reinforced this development.
From page 233...
... Since 1982, it has required that dialysis units have a training and examination program, certified by the state, that includes fluids and electrolytes, kidney disease and treatment, dietary management, principles of dialysis, dialysis technology, and dialysis patient care.
From page 234...
... 1987. Effects of the 1983 "Composite Rate" Changes on ESRD Patients, Providers, and Spending.
From page 235...
... 1990. Analysis of data related to the 1976-1989 patient population: Treatment characteristics and patient outcomes.


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